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Background: Parkinsonism, including Parkinson's disease (PD) are progressive neurological conditions. As these condition progress, individuals will need more support with their care needs to maintain independent community-living. Care needs are mainly met by unpaid, informal caregivers, usually close family members or friends. Caregiver strain is thought to lead to the need for care home placement when the caregiver can no longer cope., Objective: To understand predictors of caregiver strain and its influence on care home placement for people with moderate to advanced Parkinsonism., Methods: This is a convergent mixed methods study. Quantitative data, following an adapted stress-appraisal model, were collected on caregiver profile, tasks performed and causes of caregiver strain. Semi-structured, in-depth interviews were conducted with caregivers of people with PD (PwP) who went into a care home during the study period, to develop a deeper understanding of the caregiver role and the factors influencing caregiver strain., Results: Quantitative data were collected from 115 patient caregiver dyads. Interviews were conducted with 10 caregivers. A model to predict caregiver strain was developed and predictors of caregiver strain were identified, such as functional disability and poor caregiver sleep., Conclusion: Our findings further demonstrate the complexity of carer strain. Particular dimensions are identified that need to be addressed within clinical practice to reduce carer strain and support people with Parkinsonism to remain within their own home for as long as possible.

Background: Parkinson's disease (PD) is a multi-system disorder that can impact on driving ability. Little is known about how these changes in driving ability affect people with PD, making it difficult for clinicians and carers to offer appropriate support., Objective: To assess patient views concerning the effect of PD on their driving ability, the impact of these changes and how they manage them., Method: An online survey was created by a team of clinicians, people with PD, their carers, and representatives from Parkinson's UK. People with PD throughout the United Kingdom were invited to participate through Parkinson's UK's website, newsletter and Parkinson's Excellence Network email list., Results: 805 people with PD took part in the survey. We found that the loss of a driving licence had an adverse impact on employment, socialisation, travel costs and spontaneous lifestyle choices. Multiple changes in driving ability related to PD were described, including that impulse control disorders can have an adverse impact on driving. Changes in driving ability caused people to change their driving practices including taking shorter journeys and being less likely to drive at night. Participants advised managing changes in driving ability through planning, vehicle adaptions, maintaining skills and self-assessment., Conclusion: This study demonstrates the impact that changes in driving ability can have on the lifestyle of people with PD and reveals the strategies that individuals adopt to manage these changes.

Background: People with Parkinson's disease (PD) have higher rates of hospitalisation and healthcare utilisation compared to the general population. The COVID-19 pandemic caused significant changes in admissions to hospital and access to healthcare. People with PD are some of the most vulnerable to such changes. There is no pre-existing data on the cause and duration of admission to hospital of people with PD during the COVID-19 pandemic., Objective: To determine the cause, duration, and outcome of hospital admissions to Northumbria Healthcare NHS Foundation Trust (NHCFT) for people with idiopathic Parkinson's disease (IPD) in 2020., Methods: All people with IPD who had an emergency admission to NHCFT between 01/01/2020 and 31/12/2020 were identified. Demographic and disease characteristics, the number, duration, cause of admission and the location prior to admission were collected from an audit of medical notes., Results: 271 people with IPD had one or more emergency admissions to NHCFT between 01/01/2020 and 31/12/2020. There was a total of 453 emergency admissions, with a median duration of 5 (IQR 2-13) days. The most common causes of admission to hospital were PD-related motor dysfunction (includes falls with no other underlying cause or associated injury) and injury (includes falls with fracture), at 78 (17.2%) and 70 (15.5%) respectively., Conclusions: People with IPD had a short duration but high number of emergency admissions to hospital. Our chronological data on number of admissions shows a peak in admissions during August 2020. As a result of these findings and emerging data we suggest that individuals with PD deconditioned during 2020.

Introduction: Endogenous brain-derived neurotrophic factor (BDNF) is thought to be protective against the neurodegeneration seen in Parkinson's disease (PD), and is thought to increase during exercise. This has been proposed as a possible mechanism by which exercise improves outcomes for people with PD. We conducted a pilot study to investigate the role of exercise intensity on BDNF levels in people with PD., Methods: Participants of early- to mid-stage disease were recruited from a single PD service in north-east England, UK into two separate studies of exercise in PD, one involving moderate-intensity continuous training (MICT) and one involving high-intensity interval training (HIIT), both had control groups. In both the interventions, participants exercise three times per week for 12 weeks. Blood samples were taken for BDNF analysis at the start and end of the first session and the start and end of the final session, with corresponding samples taken in controls., Results: Data were available for 27 participants (13 intervention, 14 control) in the MICT intervention and 17 (9 intervention, 8 control) in the HIIT intervention. BDNF level did not rise significantly from the start to end of individual sessions. Across the 12 week period, they rose significantly in the HIIT intervention group, but not in controls or the MICT intervention group., Conclusions: High-intensity interval training appears to have a greater impact on BDNF than MICT. Future work should directly compare exercise modalities and investigate the impact of BDNF levels on disease progression and quality of life.

Introduction: Parkinson's disease is the second most common chronic neurodegenerative condition with bladder dysfunction affecting up to 71%. Symptoms affect quality of life and include urgency, frequency, hesitancy, nocturia and incontinence. Addressing urinary dysfunction is one of the top 10 priority research areas identified by the James Lind Alliance and Parkinson's UK., Objectives: Conduct a randomised controlled trial (RCT) targeting people with Parkinson's disease (PwP) who have self-reported problematic lower urinary tract symptoms, investigating the effectiveness of transcutaneous tibial nerve stimulation (TTNS) compared with sham TTNS. Implement a standardised training approach and package for the correct application of TTNS. Conduct a cost-effectiveness analysis of TTNS compared with sham TTNS., Methods and Analysis: An RCT of 6 weeks with twice weekly TTNS or sham TTNS. Participants will be recruited in 12 National Health Service neurology/movement disorder services, using a web-based randomisation system, and will be shown how to apply TTNS or sham TTNS. Participants will receive a weekly telephone call from the researchers during the intervention period. The trial has two coprimary outcome measures: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and the International Prostate Symptom Score. Secondary outcomes include a 3-day bladder diary, quality of life, acceptability and fidelity and health economic evaluation. Outcomes will be measured at 0, 6 and 12 weeks.A sample size of 208 randomised in equal numbers to the two arms will provide 90% power to detect a clinically important difference of 2.52 points on the Internatioanl Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) and of 3 points in the International Prostate Symptom Score total score at 12 weeks at 5% significance level, based on an SD of 4.7 in each arm and 20% attrition at 6 weeks. Analysis will be by intention to treat and pre defined in a statistical analysis plan ETHICS AND DISSEMINATION: East of Scotland Research Ethics Service (EoSRES), 18/ES00042, obtained on 10 May 2018. The trial will allow us to determine effectiveness, safety, cost and acceptability of TTNS for bladder dysfunction in PWP. Results will be published in open access journals; lay reports will be posted to all participants and presented at conferences., Trial Registration Number: ISRCTN12437878; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objectives: We hypothesized that the number and length of hospital admissions in people with Parkinson's disease (PD) would increase immediately prior to admission to a care home relative to those who were able to continue living at home or who died. Method: PD patients at Hoehn and Yahr Stages III to V were followed-up over two and a half years with deaths and care home placements recorded. Hospital admissions data were collected over this period. Results: Of 286 patients included in the study, 7.3% entered a care home and 28.3% died. In the final 120 days prior to the study exit point (care home placement, death, or continued living at home), longer hospital stay was significantly associated with care home placement, after adjusting for the competing risk of death. Conclusion: Our data provide evidence that, for many people with PD, a period of crisis is reached immediately prior to care home placement.

Parkinson's disease is a chronic multi-system disease that can cause motor and non-motor symptoms, cognitive changes and variably effective medications. Optimal management of the condition requires a multi-disciplinary team of healthcare professionals to work closely with the patient and their carers. The National Institute for Health and Care Excellence published updated guidelines on managing Parkinson's disease in adults in 2017. Here we discuss the implications of this guidance to current healthcare professionals involved in the care of people with Parkinson's disease. The guidance highlights the importance of clear communication with people with Parkinson's disease. We discuss examples of this, including providing a point of contact with specialist services for people with Parkinson's disease and ensuring information about the risks of impulse control disorders are given to people on dopaminergic therapy. The breadth of services required by people with Parkinson's disease is also described, including the need for access to physiotherapy, occupational therapy and speech and language therapy as well as treatment monitoring services for Clozapine. In addition, we emphasise the continued importance of ensuring people with Parkinson's disease receive their medications on time when in hospital or a care home., (© The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Many people with Parkinson's disease (PD) (PwP) require care from either informal or formal carers, due to worsening symptoms. Carer strain is a recognised consequence of caring. However there are few data on the role and profile of informal carers and if this impacts on carer strain., Method: People with moderate to advanced PD, with an informal carer were invited to participate. Data regarding motor and non-motor symptoms of the participant, along with demographics, tasks and duration of caring and health issues of the carer were collected., Results: One-hundred and fifteen participants and their carer were recruited. Mean carer age was 70.7 years, 66.1% were female caring for a median of 16 hours per day. Over 80% provided help in housework and companionship activities, 63.2% with dressing and 49.1% with feeding. There was a significant relationship between disease stage and level of strain. Participant age, physical and cognitive disability were significantly associated with greater care need. High care need was associated with poor carer quality of life., Conclusions: The care needs of PwP are considerable. To reduce carer strain and improve quality of life, carers' needs must be considered to enable them to carry on with their vital role.

Objectives:: To investigate whether people with Parkinson's disease can exercise at a high-intensity across a 12-week intervention and to assess the impact of the intervention on cardiorespiratory fitness., Design:: This is a randomized, controlled, feasibility study with waiting list control. Assessors were blinded to group allocation., Setting:: The intervention took place at an exercise centre and assessments at a district general hospital., Subjects:: This study included 20 people with idiopathic Parkinson's disease., Intervention:: A total of 36 exercise sessions over 12 weeks, with each session lasting ~45 minutes, were conducted., Main Measures:: The main measures were maximal heart rates achieved during exercise, recruitment rate, attendance, drop-out, change in peak oxygen consumption, cardiac output, cognitive function and quality of life. The study was considered technically feasible if participants achieved ⩾85% of maximal heart rate during exercise., Results:: There were 12 male and 8 female participants; they had a mean age of 68.5 years (standard deviation 6.825). Two participants were of Hoehn and Yahr stage I, 11 stage II and 7 stage III. In all, 17 participants completed the intervention. The median (interquartile range) proportion of repetitions delivered across the intervention which met our high-intensity criterion was 80% (67% to 84%). Mean peak heart rate was 88.8% of maximal. Peak oxygen consumption increased by 2.8 mL kg -1  min -1 in the intervention group and 1.5 mL kg -1  min -1 in the control group after 12 weeks of exercise. We estimate that a fully powered randomized controlled trial would require 30 participants per group., Conclusion:: High-intensity interval exercise is feasible in people with Parkinson's disease. Improvements in cardiorespiratory function are promising.

Background: In the United Kingdom, people with Parkinson disease (PD) and atypical parkinsonism will require more support with their care needs as the condition progresses. There are few data on the nature of care input required and the amount of informal and formal care needed by people with PD to enable them to remain within their own home., Method: All people with moderate to advanced stage (Hoehn and Yahr III-V) idiopathic PD and atypical parkinsonism under the care of the Northumbria Healthcare NHS Foundation Trust PD service and living in their own home were invited to take part in The Northumbria Care Needs Project, a 10-year prospective longitudinal study. At baseline, data regarding formal (paid) personal and domestic care input and use of respite care, sitting services, and day centers were collected. We also collected data on patient cognitive disability, functional disability, and disease severity and informal carer tasks., Results: Of 162 people with PD included in the study, only 25.2% accessed formal domestic care and the same proportion formal personal care. In contrast, 80.2% identified an informal carer who helped with these tasks. Despite greater level of functional disability in those with an informal carer, levels of formal personal care input were similar to those with and without a formal carer. Levels of formal domestic carer input were higher in those without an informal carer., Conclusions: Use of formal care services was relatively uncommon in our cohort and much of the burden of caring appears to be being met by informal carers.

2017 marks 200 years since James Parkinson's published his 'Essay on the Shaking Palsy'. Although now most famous for describing the condition that came to bear his name, Parkinson had a wide range of interests and his influence spread beyond medicine. In this review, we provide a biography of James Parkinson's remarkable life.Parkinson's paper not only comprehensively described the symptoms of Parkinson's disease (PD), but challenged his peers to better understand the pathophysiology of the PD. Key observation over the next 2 centuries, included the recognition of the link between the substantia nigra and PD and the discoveries of dopamine deficiency in patients with PD. We review the subsequent development of pharmacological and surgical therapies. Despite great progress over the last 200 years, Parkinson's hopes for a 'cure if employed early enough' or that 'some remedial process may ere long be discovered by which at least the progression of the disease may be stopped' remain apposite today and we reflect on the challenges ahead for the next century.

Introduction: Current PD assessment methods have inherent limitations. There is need for an objective method to assist clinical decisions and to facilitate evaluation of treatments. Accelerometers, and analysis using artificial neural networks (ANN), have shown potential as a method of motor symptom evaluation. This work describes the development of a novel PD disease state detection system informed by algorithms based on data collected in an unsupervised, home environment. We evaluated whether this approach can reproduce patient-completed symptom diaries and clinical assessment of disease state., Methods: 34 participants with PD wore bilateral wrist-worn accelerometers for 4 h in a research facility (phase 1) and for 7 days at home whilst completing symptom diaries (phase 2). An ANN to predict disease state was developed based on home-derived accelerometer data. Using a leave-one-out approach, ANN performance was evaluated against patient-completed symptom diaries and against clinician rating of disease state., Results: In the clinical setting, specificity for dyskinesia detection was extremely high (0.99); high specificity was also demonstrated for home-derived data (0.93), but with low sensitivity (0.38). In both settings, sensitivity for on/off detection was sub-optimal. ANN-derived values of the proportions of time in each disease state showed strong, significant correlations with patient-completed symptom diaries., Conclusion: Accurate, real-time evaluation of symptoms in an unsupervised, home environment, with this sensor system, is not yet achievable. In terms of the amounts of time spent in each disease state, ANN-derived results were comparable to those of symptom diaries, suggesting this method may provide a valuable outcome measure for medication trials., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: People with Parkinson's disease (PD) and parkinsonism living in care homes (residential or nursing care) in the UK represent around 10-15% of all people with PD and 3-5% of all care home residents. There are few previous data on medication use in those living in care homes with PD. In this study we aimed to compare medication use in a representative cohort of people with PD living in care homes in north-east England with those living in their own homes., Method: All people with late stage (Hoehn and Yahr III-V) idiopathic PD, PD dementia, or atypical parkinsonian syndromes under the care of the Northumbria Healthcare NHS Foundation Trust PD service on 1st January 2015 were identified. Demographic, disease characteristics and medication use data were collected from an audit of medical notes of all those identified., Results: We identified 377 people who met the inclusion criteria, 91 (24.1%) of whom were living in a care home. Disease stage, age and age at disease onset were all significantly higher and levodopa equivalent dose significantly lower in those living in care homes, although disease duration and levodopa dose were not. Greater age, lower levodopa equivalent dose and higher disease stage were independently associated with being in a care home., Conclusions: Although people in care homes had more advanced disease, they were on a significantly lower levodopa equivalent dose. This is likely to be due to the requirement to balance symptom management with drug side-effects., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Remote monitoring of symptoms in Parkinson's disease (PD) using body-worn sensors would assist treatment decisions and evaluation of new treatments. To date, a rigorous, systematic evaluation of the acceptability of body-worn sensors in PD has not been undertaken., Materials and Methods: Thirty-four participants wore bilateral wrist-worn sensors for 4 h in a research facility and then for 1 week at home. Participants' experiences of wearing the sensors were evaluated using a Likert-style questionnaire after each phase. Qualitative data were collected through free-text responses. Differences in responses between phases were assessed by using the Wilcoxon rank-sum test. Content analysis of qualitative data was undertaken. "Non-wear time" was estimated via analysis of accelerometer data for periods when sensors were stationary., Results: After prolonged wearing there was a negative shift in participants' views on the comfort of the sensor; problems with the sensor's strap were highlighted. However, accelerometer data demonstrated high patient concordance with wearing of the sensors. There was no evidence that participants were less likely to wear the sensors in public. Most participants preferred wearing the sensors to completing symptom diaries., Conclusions: The finding that participants were not less likely to wear the sensors in public provides reassurance regarding the ecological validity of the data captured. The validity of our findings was strengthened by "triangulation" of data sources, enabling patients to express their agenda and repeated assessment after prolonged wearing. Long-term monitoring with wrist-worn sensors is acceptable to this cohort of PD patients. Evaluation of the wearer's experience is critical to the development of remote monitoring technology.

Background: Disability is associated with increasing age and poverty, yet there are few reliable data regarding disability amongst the elderly in low-income countries. The aim of this study was to compare disability levels for three of the most common neurological, non-communicable diseases: dementia, stroke and Parkinson's disease (PD)., Methods: We performed a community-based study of people aged 70 years and over in 12 randomly selected villages in the rural Hai district of Tanzania. Participants underwent disability assessment using the Barthel Index, and clinical assessment for dementia, stroke and PD., Results: In a representative cohort of 2232 people aged 70 years and over, there were 54 cases of stroke, 12 cases of PD and estimated (by extrapolation from a sub-sample of 1198 people) to be 112 cases of dementia. People with stroke were the most disabled, with 62.9% having moderate or severe disability. Levels of moderate or severe disability were 41.2% in people with dementia and 50.0% in people with PD. However, the higher prevalence of dementia meant that, at a population level, it was associated with similar levels of disability as stroke, with 18.5% of 249 people identified as having moderate or severe disability having dementia, compared to 13.7% for stroke and 2.4% for PD., Conclusions: Levels of disability from these conditions is high and is likely to increase with demographic ageing. Innovative, community-based strategies to reduce disability levels should be investigated.

Aim: The care needs of people with Parkinson's disease (PD) are poorly understood. We aimed to investigate the factors that precipitate entry to institutional care, and on-going care needs once in care, within a representative cohort of community-dwelling people with PD., Method: All people with idiopathic PD, Parkinson's plus syndromes and vascular parkinsonism under the care of the Northumbria Healthcare NHS Foundation Trust PD service who were living in care homes on 1 January 2013 were included. Disease severity (Hoehn and Yahr stage) and demographic data were collected. Admissions to hospital over the previous 2 years and in the year before institutional care admission were documented., Results: A total of 90 patients (51 females) with a mean age of 81.3 years were included. During care home stay, the median number of emergency department attendances, the median number of hospital admissions and the median length of stay for those admitted per year were significantly lower than before care home admission. Both before care home admission and during care home stay, falls were the most common diagnoses in people attending emergency departments, with 32 of 65 (49.2%) admissions before and 34 of 59 (57.6%) admissions during care home stay having falls recorded as a cause of attendance., Conclusions: Hospital attendances and admissions were relatively common, even after institutional care home placement. Events precipitating admission, such as falls, might be preventable. PD nurse specialists could be an effective way to help train staff in homes where someone is known to have PD., (© 2013 Japan Geriatrics Society.)

Background: Caregiver burden includes the many physical, mental and socio-economic problems arising from caring for individuals with chronic and disabling diseases. Being a carer in sub-Saharan Africa (SSA), where little is known about chronic neurological conditions, may be extremely demanding. Conversely, multigenerational living may allow sharing of care among many caregivers. We wished to determine the relative burden of caring for two chronic neurodegenerative conditions (Parkinson's disease (PD) and dementia) in rural Tanzania., Methods: All surviving patients from a PD prevalence study, newly identified people with PD from a neurological disorders study and all people with dementia from a dementia prevalence study in Hai, rural Tanzania, were invited to participate. The Zarit Burden Interview (ZBI) was used to determine level of caregiver strain (higher score reflects more strain)., Results: Of 25 PD patients ZBI was recorded in 20 (14 male). Five had no identifiable carer as they were largely independent. Three had PD dementia (PDD). Of 75 people with dementia (excluding 3 PDD), 43 (32 female) completed the ZBI. For the other 32, the caregivers felt the care they provided was a normal intergenerational expectation. Median ages were 78.5 and 85 years for PD and dementia, respectively. Median ZBI was 30.5 for PD and 14 for dementia (U = 166.0, z = -3.913, p < 0.001). Disease duration and disease type (PD or dementia) were univariate predictor of ZBI score, although only disease type was predictive by multivariable linear regression., Conclusions: Caring for an individual with PD may be more burdensome than caring for an individual with dementia in SSA. People with more advanced PD had higher caregiver burden.

Background: The UK National Institute for Health and Clinical Excellence guidelines state that palliative care options for people with Parkinson's disease (PD) should be discussed., Aims: To investigate whether palliative care guidelines are adhered to for people with PD who die in hospital., Setting/participants: The medical notes of all people with a diagnosis of idiopathic PD who were living in two adjacent areas of northeast England and who died over a 3-year period were examined. Demographic data and specific information regarding events around the time of death were recorded., Results: For the 236 patients identified, the average age at death was 82.8 years. Of these patients, 110 (46.6%) died in hospital, 56 (23.7%) at home, 59 (25.0%) in a care home and for 11 patients (4.7%) the place of death was not recorded. For those who died in hospital, only three patients, and seven relatives of patients, had had a recorded discussion with a clinician regarding their preferred place of death and only 15 (13.6%) were referred to a specialist palliative care team. Forty-six patients (41.8%) were placed on the Liverpool Care Pathway., Conclusions: For those dying in hospital, there are few previously documented end-of-life care discussions with patients or their relatives. The use of end-of-life pathways and access to specialist palliative care is variable. Following the Neuberger report, the Liverpool Care Pathway is to be replaced with individual end-of-life care plans. It is important to engage patients, and their relatives, in decision making regarding preferences at the end of life.

Background: Autonomic dysfunction is common in patients with Parkinson's disease (PD). We report autonomic function test results in a prevalent, largely untreated, Tanzanian population of PD patients, at different disease stages and investigate the relationship between autonomic dysfunction and mortality., Methods: Ewing's battery of autonomic tests was carried out on a prevalent population of PD patients living in the rural Hai district of Tanzania. Where possible, all four tests were performed in the patient's home. The main outcome of interest was the presence of abnormalities of sympathetic or parasympathetic function. Information on medications used and other co-morbidities was recorded., Results: Autonomic function tests were recorded for 29 subjects, of whom 3 were on medication at the time of assessment. Of the 26 unmedicated patients, 14 (53.8%) had at least one abnormal test result for autonomic function, of whom only 3 (21.4%) were in late stage disease (Hoehn and Yahr stage IV or V), compared to 7 (58.3%) of 12 with normal autonomic function tests in late stage disease. Ten subjects had died at 5-year follow-up, but there was no association between mortality and autonomic function test abnormalities., Conclusions: In unmedicated subjects, many patients in late stage disease had relatively preserved autonomic function, compared to those in early stage disease. In people with PD who are taking medication, it may be that when autonomic dysfunction presents in late stage disease it is often due to side effects of medication rather than the disease itself.

In Parkinson's disease (PD) typical "palliative care" type symptoms, such as pain, nausea, weight loss and breathlessness can occur throughout the condition, but become more prevalent in later disease stages. Pain may be specifically related to PD, e.g. dystonic pain with wearing off, but is more commonly due to other conditions. The cause can usually be elicited by a careful history and examination, and this guides intervention, both non-pharmaceutical, and pharmaceutical. For example, dystonic pain will respond best to appropriate changes to dopaminergic medication. In later disease stages people have increasing problems with swallowing, and also cognitive impairment. Impaired swallowing may lead to aspiration pneumonia, which is a common cause of hospital admission, and also death. Decisions about interventions towards the end of life, such as insertion of percutaneous endoscopic gastrostomy (PEG) tube for nutrition, can be very challenging, particularly if, as in most cases, the person with PD has not previously expressed their views upon this while they still maintained capacity to make decisions. Advance care planning (ACP) in PD should be encouraged in relation to interventions such as PEG tubes. It may also cover issues such as preferred place of death. Over recent years lower proportions of people have been dying at home, and this is especially true for PD, but home may well be where they would have preferred to die. However, there is little evidence to guide health professionals about how, when, and by whom, ACP should be approached.

The incidence of hip fracture and outcomes from hip surgery for people with Parkinson's disease (PD) are thought to be poorer than for people without PD. The aim of this audit of a prospective hip-fracture database was to establish the incidence of, and outcomes from, hip fracture in people with and without PD living in North East England. The number of people with PD living in the study area was estimated using data from two previous prevalence studies in the same geographical area. Using data collected prospectively for the National Hip Fracture Database for Northumbria Healthcare National Health Service Foundation Trust in the UK, the annual incidence of hip fracture in people with and without PD was calculated. Type of fracture, time to surgery, time to discharge, and 30-day outcomes from surgery were compared. Annual incidence of hip fracture was significantly higher in people with PD across all age bands. In those 60 years of age and over, it was 2,171 (95% confidence interval [CI]: 2,082-2,264) per 100,000 in people with PD and 551 (95% CI: 506-598) in people without PD. The experience of PD and non-PD patients within hospital was remarkably similar. However, PD patients had poorer mobility before hip fracture, took longer to be discharged to the community, and were less mobile postsurgery. Specific guidelines for managing people with PD who sustain a hip fracture may help to improve awareness of the potential complications of the condition and improve outcomes., (© 2012 Movement Disorder Society.)

Background: Parkinson disease (PD) causes physical disability that negatively affects the quality of life of the sufferer's and their families. There are no Parkinson's disease (PD) social science studies published from Africa. This paper presents findings from a qualitative research study on how PD is perceived and treated in a population of approximately 161,000 within a demographic surveillance site in rural Tanzania., Methods: We conducted in-depth interviews with 28 PD sufferers, 28 carers, 4 health workers and 2 traditional healers. In addition, 6 focus group discussions were conducted in 3 villages to investigate wider community views of PD., Results: PD sufferers expressed frustration with the physical, psychological, social and economic consequences of the illness. Feelings of a diminished quality of life characterised by dependency, stigma and social isolation were common. Additionally, a handful of male sufferers related their sexual incompetence to the illness. Carers complained of lost income opportunities and social isolation resulting from caring for sufferers. Misconceptions about the cause, symptoms and appropriated PD treatment were widespread. Only 2 PD sufferers had commenced western type treatment through outsourcing drugs from other parts of the country and outside of Tanzania., Conclusions: This study highlights the urgent need for PD awareness and treatment interventions in such settings. Such interventions need to address the concerns and needs of sufferers, their carers and the wider community, including the health care system., (© 2011 Mshana et al; licensee BioMed Central Ltd.)

Aims and Objectives: We aimed to investigate the effect of active dose and dose per kilogram (kg) of body weight of levodopa on the occurrence of dyskinesia within a prevalent population of people with PD., Methods: Of 106 prevalent cases, 75 (70.8%; 38 males, 37 females) agreed to assessment by a member of the research team. Demographic information, weight and height were recorded. Patients were assessed using a range of rating scales including the Unified Parkinson's Disease Rating Scale. Patients were asked specifically: 'Do you have, or have you ever had, dyskinesia?'., Results: Nine patients (12.0%) reported dyskinesia. Patient reported dyskinesia was significantly associated with greater years since diagnosis (r=0.309, p=0.007), higher levodopa equivalent dose (r=0.406, p<0.001) and levodopa equivalent dose per kg body weight (r=0.375, p<0.001). Using logistic regression, active levodopa dose, unadjusted for body weight, was an independent predictor of dyskinesia., Conclusions: Adjusting levodopa dose for body weight did not increase its degree of correlation with patient reported dyskinesia., (© 2010 Elsevier Ltd. All rights reserved.)

Background: Parkinson's disease (PD) patients have an increased risk of under-nutrition, but we are unaware of any population based prevalence studies of under-nutrition in PD. The main objective of this study was to identify the prevalence, and nature, of under-nutrition in a representative population of people with PD., Methods: People diagnosed with idiopathic PD from within two PD prevalence study sites in North-East England were asked to participate in this study. Those who participated (n = 136) were assessed using a number of standard rating scales including Hoehn & Yahr stage and Unified Parkinson's Disease Rating Scale (UPDRS). Body mass index (BMI), mid-arm circumference (MAC), triceps skin fold thickness (TSF) and grip strength were recorded together with social and demographic information., Results: BMI < 20 identified over 15% of the study group to have under-nutrition. The Malnutritional Universal Screening Tool (MUST) scoring system identified 23.5% of participants at medium or high risk of malnutrition. Low BMI, indicating under-nutrition, was associated with greater age and disease duration, lower MAC, TSF, mid-arm muscle circumference (MAMC), reduced grip strength and a report of unintentional weight loss. Problems increased with increasing age and disease duration and were greater in females., Conclusions: Under-nutrition is a problem for around 15% of community dwelling people with PD. All PD patients should be screened for under-nutrition; the MUST score is a useful early screening tool.

Aims and Objectives: We have previously reported the age-adjusted prevalence of idiopathic Parkinson's disease (PD) in North Tyneside, an urban area of North-East England, as 139 cases (95% CI 116 to 162) per 100,000. The aim of this study was to report the prevalence of idiopathic PD in a rural area of North-East England., Methods: The same case-finding methodology as that employed in North Tyneside was used to identify cases of PD in an area of North Northumberland with a population of 59,613 at the 2001 UK census. All GPs in the study area were asked to provide details of patients registered with their service that may have PD or were on PD medication. Furthermore, all patients registered with the local PD service or under the care of a consultant neurologist or other relevant secondary care specialist were considered for inclusion. Inclusion in the study required fulfillment of the UK Brain Bank criteria., Results: One-hundred-and-six cases were identified (50 women and 56 men), giving crude and age-adjusted prevalence estimates of 178 cases (95% CI 144 to 212) and 142 cases (95% CI 118 to 165) per 100,000 respectively. The age-adjusted prevalence rate within our rural study area was remarkably similar to that seen in other urban UK studies. Only 71 cases (67.0%) were identified through GP records., Conclusions: The prevalence of PD rural and urban areas of North-East England is remarkably similar., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

The incidence of Parkinson's disease (PD) in sub-Saharan Africa (SSA) is greater than thought however, is largely undiagnosed and untreated. This study aimed to evaluate a nonpharmacological approach using cueing therapy to improve gait in drug-naïve PD and the feasibility of delivering rehabilitation in northern Tanzania. In this study, twenty-one people with PD aged 76.4 years (12.9 SD) with varying disease severity participated. They received 9 x 30 min sessions of cueing therapy for gait problems over 3 weeks from a trained therapist delivered in their home environment. Cueing therapy consisted of walking in time to a metronome beat to correct step amplitude and step frequency during a range of functional activities. Gait was recorded on video before and after therapy, and videos were analyzed in the UK by an assessor not involved in data collection. Disease severity (UPDRS) and balance were also measured. Patients were assessed in their nearest clinic. Data were analyzed in Minitab and a P value of 0.05 was considered significant. Cueing therapy significantly improved single and dual task walking speed, step amplitude, and single task step frequency. There was also a significant improvement in motor impairment (UPDRS III) and activities of daily living (UPDRS II). The results provide promising evidence for the role of cueing therapy in PD for symptom management to reduce or delay medication onset. This study also supports the feasibility of rehabilitation in PD in community environments in SSA, which may be applicable to other developing regions., ((c) 2010 Movement Disorder Society.)

Background: Parkinson's disease (PD) is the second most common neurodegenerative condition in the UK. Care needs increase as the disease progresses, but there are very few published data in relation to this., Objective: the aim of this study was to elicit the care requirements for a prevalent PD population and compare these to a similarly aged background population., Methods: all people diagnosed with idiopathic PD from within a defined area of north-east England were asked to participate in this study. Those who agreed to participate were assessed using a number of standard rating scales including Hoehn and Yahr stage, Unified Parkinson's Disease Rating Scale (UPDRS), Hospital Anxiety and Depression Scale, Parkinson's Disease Questionaire-39 and Mini-Mental State Examination (MMSE). In addition, participants were asked whether they had experienced hallucinations. Social and demographic information (e.g. age, sex and place of abode) was also recorded., Results: from all cases (n = 161), 135 people (83.8%) agreed to participate. Of these, 19 (14.1%) were living in residential or nursing homes, representing 1.6% of the total nursing/residential home residents in the study area. Participants had a mean age of 74.8 years and disease duration of 5.6 years. Those in care were significantly older and had significantly poorer Hoehn and Yahr, MMSE and UPDRS scores., Conclusion: PD patients in institutional care have poorer cognitive function, are older, have later stage disease and worse functional ability than those living at home.

The primary aim of this study was to ascertain whether a battery of physical function measures in a Parkinson's disease (PD) patient cohort predicted mortality status at 7-year follow-up. Secondary aims were establishing which specific tests were the most useful, and whether PD phenotype was a predictor. A retrospective correlation design was used in this study. A cohort of 109 PD patients underwent baseline physiotherapy assessment of gait, balance, posture, muscle strength, and ability to change postural set. We compared mortality status at 7-year follow-up and baseline physical assessment tests. Tinetti gait and balance scores, UPDRS score, 10-m walk test (time, velocity, and number of strides), posture in standing, lying to sitting, sitting to standing, getting up from floor assessments, and time to ascend and descend four steps were found to be statistically significant physical predictors of mortality at 7-year follow-up. In addition, age, sex, and mini-mental state examination were significant nonphysical predictors of mortality. Using Cox regression, a survival model was constructed with age, sex, and Tinetti gait score as independent predictors of mortality. The results of this study suggest that there is a link between reduced physical function and an increased mortality risk in PD populations.

Introduction: Most of the patients identified in a community-based prevalence study of Parkinson's disease (PD) in the Hai district, rural northern Tanzania, in 2005-2006, had not been previously diagnosed or treated., Methods: Screening methods to identify patients have been previously described. Diagnosis was confirmed by the UK, PD Society Brain Bank Criteria. Patients were assessed in their own home with the assistance of a local translator and completed: Unified PD Rating Scale (UPDRS), Non-motor Symptoms Assessment Scale, PDQ-39, Hoehn and Yahr scale, and Hospital Anxiety and Depression Scale (HAD)., Results: Thirty-three (23 male, mean age 74, range 38-94 years) patients were identified. Only 5 had ever taken PD medication, and only 3 were currently treated. Hoehn and Yahr stage ranged from 2 to 5, disease duration from 3 months to 19 years, mean UPDRS was 50 (range 24-97), mean PDQ-39 386 (range 219-580) and mean non-motor symptom scale score 62 (range 11-209). Some patients who had never taken medication for PD, and who did not fulfil the Lewy Body Dementia diagnostic criteria, had experienced visual hallucinations., Conclusions: By studying patients at varying stages of PD who have not received treatment we can learn more about the symptoms of late stage PD and ascertain whether they are drug- or disease-related, or a combination of both. Hallucinations are likely to be a manifestation of the disease, but are often precipitated or exacerbated by medication. These patients have now commenced treatment, with close monitoring for complications, including motor or neuro-psychiatric symptoms.

This study evaluated the symptom burden experienced by patients with Idiopathic Parkinson's Disease (IPD) by using a standard palliative care assessment tool (PACA) and comparing it with the Unified Parkinson's Disease Rating Scale (UPDRS). These tools together with the Mini-Mental State Examination, Beck Depression Inventory and the Schedule for the Evaluation of Individual Quality of Life were used in 123 IPD patients. The PACA demonstrated broad coverage of both motor and non motor symptoms (mean=14.3 symptoms per patient) whereas the UPDRS predominantly assessed motor symptoms. Implications for symptom assessment and palliative care provision in IPD are discussed.

Parkinson's disease (PD) is said to be less common in Africa than elsewhere in the world, but previous studies have been based on small numbers. Also, the differences may be due to the diagnostic criteria used, case finding methods and different population age structures. Developing countries have few facilities for chronic disease management and non-communicable diseases, although on the increase, tend to play second fiddle to malaria and HIV/AIDS. Previous reports suggest that, at least from anecdotal information, under-diagnosis of PD is common and long-term availability of medication, follow-up, patient education and multidisciplinary input is lacking. Published literature is scarce and there is a lack of recent information. We are currently conducting a door-to-door prevalence study in northern Tanzania in a population of 161,162. We have reviewed previous literature on PD in Africa and illustrate our personal experience of PD and its management in Africa with three cases.

The purpose of this study was to assess quality of life (QoL) of patients with idiopathic Parkinson's disease (IPD). The Parkinson's Disease Questionnaire (PDQ-39) was compared with an individualized QoL tool: the Schedule for Evaluation of Individual Quality of Life Direct Weighting (SEIQoL-DW). One hundred twenty-three patients underwent interviews using these tools, together with the Mini Mental State examination, Beck Depression Inventory, a qualitative pain assessment, and the Palliative Care Assessment tool (for symptoms). The SEIQoL-DW was well tolerated and demonstrated that QoL not only was broad and highly individualistic but also was determined more by psychosocial than physical issues. Of the 87 domains nominated by patients, the most common were family (87.8%), health (52.8%), leisure activities (36.6%), marriage (35%), and friends (30.9%). The SEIQoL index score was predicted by depression but not by disease stage. However, the PDQ-39 was predicted by disease stage, the number of symptoms, and depression. Direct comparison of the tools confirmed that the SEIQoL index score was predicted by the PDQ-39 domains of social support, cognitive impairment, and emotion. The use of the SEIQoL-DW challenges current thinking within IPD research regarding QoL and its assessment using the PDQ-39.

The aim of this study was to use both quantitative and qualitative data to assess pain in idiopathic Parkinson's disease (IPD) and classify it according to cause. In this descriptive cross-sectional study, 123 patients were interviewed and pain was assessed using patient descriptions, the Brief Pain Inventory, and Visual Analogue Scales. Patients reported 285 pains (median 2 per patient), and 22.8% had 4 or more pains. Pain was reported as a problem in 85% and was IPD-related in 62.6% of patients, unrelated to IPD in 64.2%, indirectly related to IPD in 8.1%, related to multiple causes in 4.1%, and treatment related in 0.8%. Pain unrelated to IPD was more common, more constant, and more severe than IPD-related pain. Overall, analgesic use was low. This study demonstrates the benefits of adopting a systematic and logical approach to the assessment of pain in IPD and the merits of a simple new classification system.

Background: Cognitive impairment is well recognised in Parkinson's Disease (PD) but few studies have examined cognitive decline over time in such subjects. Standard clinical assessments of cognitive function, such as the MMSE, do not measure all cognitive domains and often have a ceiling effect. CAMCOG-R provides a more comprehensive cognitive assessment allowing several different domains of cognition to be compared. It also features the ability to test 'executive function'. CAMCOG-R has only been reported on one previous occasion in PD subjects and this is the first study to report a follow-up CAMCOG-R to assess cognitive decline., Methods: In a previously published study CAMCOG-R was administered to a prevalent community-based population of 94 subjects with PD with a MMSE of 25 or above. In this subsequent study 85 of the subjects (two declined and seven were deceased) underwent a follow-up CAMCOG-R after a mean delay of 13.1 months., Results: The initial, and follow-up mean total CAMCOG-R scores were 88.65/104 and 84.75/104 respectively, demonstrating a significant decline (p < 0.05). Significant cognitive decline (p < 0.05) was also seen across every CAMCOG-R cognitive domain and in the executive function scores., Conclusions: A wide range of cognitive ability was again demonstrated using CAMCOG-R in this PD population. The decline of 3.9 CAMCOG-R points over the 13-month period compares to other previous studies showing an annual decline of 1.6 CAMCOG points in normal elderly individuals and 12 CAMCOG points annually in those with established dementia. This study suggests that CAMCOG-R is a useful and appropriate tool for use in follow-up cognitive screening in PD subjects., (Copyright (c) 2006 John Wiley & Sons, Ltd.)

Background: cognitive decline is well recognised in Parkinson's disease (PD) but the best cognitive assessment tool for use in such patients remains unclear. The 30-point Mini-Mental State Examination (MMSE), while quick and straightforward to use, fails to cover a full range of cognitive domains and is recognised to have a ceiling effect. The Cambridge Cognitive Assessment-Revised (CAMCOG-R) is a cognitive screening tool allowing the assessment of a number of different domains of cognition. It has not previously been used specifically on PD subjects., Methods: a prevalent community population of 135 PD patients were assessed cognitively using the MMSE. Those scoring 25 or above on the MMSE were subsequently further assessed using CAMCOG-R. Demographic and disease factors including disease duration, symptom severity, anxiety, depression and the presence of hallucinations were recorded for each participant., Results: 31/135 (23%) demonstrated cognitive impairment on the MMSE (score < 25). Ninety-four of the remaining group (10 were excluded) achieved a median total CAMCOG-R score of 89/104. The results were widely distributed. The subjects scored particularly highly in the cognitive domains of orientation, comprehension and perception but relatively poorly at memory and abstract thinking. Significantly poorer scores (P < 0.05) were seen throughout the cognitive domains with increasing age, increasing PD symptom severity and increasing disease duration, but not with the presence of anxiety, depression or hallucinations in the subjects., Discussion: CAMCOG-R was found to be a viable and useful cognitive screening tool for use in PD. A wide range of cognitive ability was demonstrated in subjects who had been assessed previously by the MMSE as not having significant cognitive impairment. The group performed worse in certain cognitive domains than others and those who were older, with more severe PD symptoms and with symptoms for longer, scored less well.

Objective: To study the nigrostriatal pathways in 21 patients with dementia with Lewy bodies (DLB), 19 drug naive Parkinson disease (PD) patients, and 16 controls using a dopaminergic presynaptic ligand [123I]-2beta-carbometoxy-3beta-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (FP-CIT) and SPECT in order to assess similarities or differences between DLB and PD., Methods: A SPECT scan was carried out 3 to 4 hours after administration of 185 MBq (IV) of FP-CIT. Using occipital cortex as a radioactivity uptake reference, ratios for the caudate nuclei and the anterior and posterior putamina of both hemispheres were calculated. From the FP-CIT binding measurements, asymmetry indices and caudate:putamen ratios were derived., Results: The DLB and PD groups had lower FP-CIT binding in all striatal areas than controls (analysis of variance: p < 0.001 in all measures). DLB patients also had significantly lower binding in the caudate nucleus than the PD patients. There was greater asymmetry of uptake in the posterior putamina of PD patients than DLB patients (p < 0.04) and controls (p < 0.01). The mean caudate:putamen ratio for the DLB group was not significantly different from that of the controls, while the mean caudate:putamen ratio of the PD group was higher than that of the control group (p < 0.001) and the DLB group (p < 0.001)., Conclusion: This study showed differences between PD and DLB in the pattern of striatal dopaminergic dysfunction. DLB patients do not have the characteristic selective degeneration of ventrolateral nigral neurons seen in PD. This could explain some of the clinical differences between DLB and PD.

Objectives: To accurately establish the incidence of falls in Parkinson's disease (PD) and to investigate predictive risk factors for fallers from baseline data., Methods: 109 subjects with idiopathic PD diagnosed according to the brain bank criteria underwent a multidisciplinary baseline assessment comprising demographic and historical data, disease specific rating scales, physiotherapy assessment, tests of visual, cardiovascular and autonomic function, and bone densitometry. Patients were then prospectively followed up for one year using weekly prepaid postcards along with telephone follow up., Results: Falls occurred in 68.3% of the subjects. Previous falls, disease duration, dementia, and loss of arm swing were independent predictors of falling. There were also significant associations between disease severity, balance impairment, depression, and falling., Conclusions: Falls are a common problem in PD and some of the major risk factors are potentially modifiable. There is a need for future studies to look at interventions to prevent falls in PD.